tci General Surgery Coding Alert - 2010 Issue 16

READER QUESTIONS: Capture Extra Work for Choledochal Cyst

Question: The surgeon treated a patient with a large choledochal cyst. The procedure involved an open cholecystectomy with en bloc excision of extrahepatic bile ducts (roux-en-Y reconstruction) with hepaticojejunostomy. What are the correct CPT and ICD-9 codes? Texas Subscriber Answer: The correct ICD-9 code will depend on whether the patient has an acquired or congenital choledochal cyst. You would expect to see the congenital cyst more commonly in pediatric patients. Assuming that the patient has an acquired cyst, the correct diagnosis code is 576.8 (Other specified disorders of the biliary tract). On the other hand, if your surgeon...

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